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Continuous and Coordinated Care

Health Links

Ministry of Health and Long-Term Care

Transforming Ontario’s Health Care System

Health Link is a team of providers (primary, hospital, home, community and long-term care providers; community support agencies; and other community partners) in a geographic area working together to provide coordinated health care to patients with multiple complex conditions—often seniors—with the patient at the centre. Providers design a care plan for each patient and work together with patients and their families to ensure they receive the care they need.

http://www.health.gov.on.ca/en/pro/programs/transformation/community.aspx

Health Quality Ontario

Quality Improvements: Health Links

This resource offers information on supports available to Health Links, and primary care more generally, including improvement packages on transitions of care, chronic disease management and supporting health independence.

http://www.hqontario.ca/Quality-Improvement/Quality-Improvement-in-Action/Health-Links

HLhelp@hqontario.ca

Care Coordination Resources and Guides

Association of Family Health Teams of Ontario

Diabetes Care Coordination Tool

AHFTO G Diabetes-Care-Calculator-v4

Case Studies: Care Coordination

This document looks at how five Family Health Teams have effectively embedded the Care Coordinator role within primary care. Their advice to other primary care teams, and the lessons they have learned in the process

http://www.afhto.ca/wp-content/uploads/Case-Study-Care-Coordination-2016.pdf

Safety Net Medical Home Initiative (SNMHI)

Change Concepts: Care Coordination

This guide defines care coordination and the recommended key changes needed to achieve it. It includes a Reducing Care Fragmentation Toolkit that has a detailed discussion of the basic elements of effective referral or transition management:

  • Assuming accountability for care coordination
  • Providing patient support
  • Developing relationships and agreements with key outside providers
  • Establishing connectivity that ensures appropriate information transfer.

The toolkit also includes a series of case studies and links to specific tools (e.g., job descriptions and staff training curricula). Key changes for Care Coordination are as follows:

  • Link patients with community resources to facilitate referrals and respond to social service needs.
  • Integrate behavioural health and specialty care into care delivery through co-location or referral agreements.
  • Track and support patients when they obtain services outside the practice.
  • Follow up with patients within a few days of an emergency room visit or hospital discharge.
  • Communicate test results and care plans to patients/families.

See examples of one SNMHI participant’s Care Coordination interventions and results here.

http://www.safetynetmedicalhome.org/change-concepts/care-coordination

Agency for Healthcare Research and Quality

Coordinating Care in the Medical Neighborhood: Critical Components and Available Mechanisms

This white paper describes the medical neighbourhood, assesses barriers and facilitators, and provides tools for communication and collaboration.

https://www.pcpcc.org/sites/default/files/resources/Coordinating%20Care%20in%20the%20Medical%20Neighborhood%20%283%29.pdf

University of Colorado Anschutz Medical Campus

Coordinated Care Module

This module discusses models of care coordination across a complex healthcare system, including the following:

  • Defining care coordination in primary care practice
  • Discussing methods for patient care coordination across a complex healthcare system, the practice and the patient’s family and community
  • Describing a realistic plan for improving care coordination in your practice.

https://cuelearning.org/courses/care-coordination/

Patient-Centered Primary Care Collaborative

Webinar: Care Coordination and the Patient’s Role in Shared Decision Making and Team Communication

The webinar explores the definitions of “care team” and “care coordination” as well as the key elements of care coordination. It also talks about the patient’s perspective by reviewing Christine Bechtel’s research on patients and the delivery system as a whole—its challenges and potential solutions—including care coordination and the medical home.

https://www.pcpcc.org/video/care-coordination-and-patients-role-shared-decision-making-and-team-communication

PDF presentation can be found here:

https://www.pcpcc.org/sites/default/files/media/pcpcc-_care_coord-7-12-12.pdf


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